New York State Assignment of Benefits Form

New York State Assignment of Benefits Form

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New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form

Use this form if you receive a surprise bill for health care services and want the services to be treated as innetwork. To use this form, you must: (1) fill it out and sign it; (2) send a copy to your health care provider
(include a copy of the bill or bills); and (3) send a copy to your insurer (include a copy of the bill or bills). If you
don’t know if it is a surprise bill, contact the Department of Financial Services at 1-800-342-3736.

A surprise bill is when:
1. You received services from a non-participating physician at a participating hospital or ambulatory surgical
center, where a participating physician was not available; or a non-participating physician provided services
without your knowledge; or unforeseen medical circumstances arose at the time the services were provided. You
did not choose to receive services from a non-participating physician instead of from an available participating
physician; OR

2. You were referred by a participating physician to a non-participating provider, but you did not sign a written
consent that you knew the services would be out-of-network and would result in costs not covered by your insurer.
A referral occurs: (1) during a visit with your participating physician, a non-participating provider treats you; or (2)
your participating physician takes a specimen from you in the office and sends it to a non-participating laboratory
or pathologist; or (3) for any other health care services when referrals are required under your plan.

Office Visits:

• 
  At the time your initial appointment was scheduled, you were informed of your doctor’s network status with your health insurance plan.
• 
  We participate with NY and NJ Medicare and Medicaid. Empire Healthplus and CenterLight PACE Plan.
• 
  A list of the hospitals we are affiliated with is available online at or upon request.
• 
  If your doctor participates with your plan, a co-payment may be due at the time of your appointment.
• 
  If your doctor does not participate in your plan but your plan provides out of network benefits, we will file a claim on your behalf and work with your insurance carrier to obtain payment. As required by law, and in accordance with the terms of your policy, you may be responsible for any deductible or co-insurance amounts which may apply.
• 
  An estimated amount for services to be performed, absent unforeseen circumstances, is available upon request.
• 
  Missed appointments. Our policy is to charge $50.00 for missed appointments not canceled within 24 hours. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointments
• 
  Bounced checks will incur a fee of $50.00

Procedures

In addition to all the policies listed above:

• 
  If your doctor recommends a procedure, and your doctor is in-network, you may be responsible for any in-network fees or deductibles which may apply. Please consult with your insurance carrier.
• 
  If you are scheduled for a procedure, other providers from our office providing necessary services will submit a separate bill to your insurance carrier under the same conditions as above.
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  The proper care and treatment of our patients is our top priority, and we will work with our patients to provide a fair and reasonable settlement of any financial obligation. We understand that personal financial circumstances vary from patient and to patient. If you are suffering from a financial hardship, please discuss this with our billing department. Our billing department is available to speak with patients who have questions at (201)-387-1957.

I have read and understand the above financial policy. I understand that I may contact the billing department at (201)
387-1957 with further questions.